Bottom Line

This is a fun and stimulating read for anyone interested in depression and other mood disorders.

Overview

On Depression by Nassir Ghaemi is aimed at a general, educated audience. He advances several points. The current classification of mood illnesses is based on pragmatic, not scientific considerations and doesn’t respect biological facts. Therefore, our understanding of mood disorders, depression in particular, has not advanced much. Instead of current practice, depression should be considered a mental disease if and only if it is recurrent. For this illness we should find treatments through proper research into biological causes. The vast majority of current instances of depression are not a (medical) disease. Instead they are, as the existentialists suggested, an unavoidable part of human life. Certainly we should aim at relieving the suffering, but the proper response is to deal with the existential problems instead of medicating away the symptoms.

Most Depression is Not a Disease

Recent books on the status of depression tend to view all depression as illness requiring treatment (pills or therapy), view only major depression as justifying treatment, or tout the benefits of melancholia to human growth. In all these discussions, it is taken for granted that the severity of symptoms (according to common sense or some version of the DSM) or trigger (upset over minor stress or understandable grief) allows a classification of cases of depression as either illness (major depressive disorder) or merely a low mood after a difficult life event. Ghaemi, refreshingly, argues for a completely different approach. According to him, mood disease is defined by recurrent episodes for which anything can be a trigger. One-off depressions, no matter how painful or debilitating are not diseases. This is quite different than the current division of mood disorders into those with manic episodes (bipolar disorder) and those without (major depressive disorder). But, says Ghaemi, whether mood is too high (manic) or too low (depressed) is not what distinguishes illness from a natural reaction to life. Because we are using false categories in research, research is not progressing much.

Western societies already have to face the sad fact that helping those with mood disorders has not much progressed since lithium and tricyclic antidepressants were discovered. Many of our mentally ill are in jail or homeless. But if Ghaemi is correct (and I’m inclined to belief he is), we’re wasting a lot of money on research which cannot be successful. Ghaemi uses syphilis as an illustration. When the syphilis-causing bacterium was discovered, clinicians had through careful observation identified a clear subgroup among those in mental asylums. When the syphilis blood test mapped those who were infected mapped onto the identified group, neurosyphilis was identified. Had the mental patients been classified according to pragmatic DSM-criteria, those infected with syphilis would have been placed in different subgroups and we would not have discovered that a certain kind of mental illness can be avoided by early syphilis treatment. Similarly, categorization of depression by practical consideration may be the reason that some patients are greatly helped by antidepressants while others show little effect and why some are greatly helped by psychotherapy and others not.

Postmodernism and the DSM

The division of mood disorders according to recurrence has been suggested before and was even used for a while. Ghaemi blames the loss of this insight on postmodernism, which he defines as the belief that the "modernist goal of discovering the truth through reason and science (the Enlightenment project) has failed. All ideas are merely based in culture and easily adjusted when beliefs change. This attitude allowed practical concerns to outweigh scientific insight. The reasonable order is to identify illnesses first and then develop treatments for them. But after the initial success of antidepressants, profit driven companies created illnesses to fit their medications and initiated major ad campaigns to help people realize that they had these illnesses. This then also led to changes in the DSM such as the addition of dysthymia and Generalized Anxiety Disorder which then also allowed psychotherapists to bill for these "diseases."

Ghaemi criticizes the approach taken in the DSM IV: science is deliberately considered least relevant for diagnosis, pragmatics most relevant. These pragmatic concerns include beliefs of clinicians, wishes of patients, general ignorance about many scientific facts, limitations of treatments, and the needs of insurance reimbursements. The wide use of DSM criteria has achieved high levels of reliability, but because of lack of a link to scientific fact, there had been little progress in validity, resulting not only in inefficient treatment but also in unsuccessful research.

Hippocrates versus Galen

I found the discussion of the Hippocratic and Galenic traditions in medicine particularly interesting. Hippocrates advocated that nature is the best healer and thus the physician should only aid nature in healing, and this only when the benefits of interfering clearly outweigh negative side effects. Galen, on the other hand, viewed nature as the cause of illness which physicians should fight with everything available to them. The Galenic tradition brought us bloodletting, induced vomiting and emetics. Any interference is better than allowing the illness to take its course. According to Ghaemi, psychosurgery, electroshock therapy and much of our psychopharmacology are squarely in the Galenic tradition causing more harm than good. This is because we don’t have a good understanding of mood disorders yet clinicians feel the need (and societal pressure) to do something, anything to fight back mental disorders and fix what is wrong.

Ghaemi sees himself in the tradition of Hippocrates and advocates that medicine return to this model.

In order to do that he suggests two rules. First (credited to William Osler), "Treat diseases, not symptoms." Second (credited to Oliver Wendell Holmes), "All medications are guilty [harmful] until proven innocent." Following these two rules would encourage more careful diagnosis based on biological reality (instead of pragmatic desires) and eliminate all the extra suffering caused by many current treatments.

Helping Those with Non-Disease Depression

If only recurrent mood episodes indicate illness, what are we to do with all those who are suffering from a single but severe depression, anxiety or dysthymia? These patients are the vast majority of cases encountered by clinicians. Even if they don’t have a medical illness, their suffering is real and they deserve relief. Ghaemi sees as the cause of their suffering the unavoidable anxiety of human lives already identified by the existentialists. It is only through coming to terms with the loneliness and Angst of the human condition brings not only relief but also valuable insight and growth. To give us some idea how this may be done, Ghaemi devotes several interesting chapters to "guides" which can show us ways to deal with this: Victor Frankl, Rollo May, Elvin Semrad, Leston Havens, Paul Roazen, and Karl Jaspers. Ghaemi extracts from each a helpful response to the difficulties of being human.